Case 37: Urinary retention

 

Case 37: Urinary retention

CASE 37: URINARY RETENTION

History

A 29-year-old woman presents to the emergency department having been unable to pass

urine for 8 h. For the last 3 days she has been feeling unwell with a fever, shivering and a

reduced appetite. She has pain in her groins specifically but says that her whole body aches.

Yesterday she began to feel pain on passing urine, and today this has became very severe such

that now she cannot micturate at all. She has never experienced any episodes like this before.

She has no previous medical or gynaecology history and has regular menstrual cycles. She

recently ended a long-term relationship and has been with a new partner for a few months,

with whom she uses condoms.

Examination

The woman is obviously in significant discomfort. Her temperature is 37.4°C, heart rate 102/

min and blood pressure 118/80 mmHg. Bilateral tender inguinal lymphadenopathy is noted

and axillary lymph nodes are also palpable. The bladder is palpable midway to the umbilicus. The vulva is generally reddened and there is a cluster of ulcerated lesions of approximately 2–5 mm on the left side of the labia minora. Speculum examination shows the cervix

is inflamed with a profuse exudate.

INVESTIGATIONS

Normal range

Haemoglobin 12.7 g/dL 11.7–15.7 g/dL

White cell count 12×109/L 3.5–11×109/L

Neutrophils 3.2×109/L 2–7.5×109/L

Lymphocytes 9×109/L 1.3–3.5×109/L

Platelets 272×109/L 150–440×109/L

Questions

• What is the diagnosis?

• How would you further investigate and manage this patient?100 Cases in Obstetrics and Gynaecology

90

ANSWER 37

The woman is demonstrating a classic presentation of primary herpes simplex virus infection. Prodromal ’flu type symptoms and generalized lymphadenopathy usually occur most

significantly with primary infection, and any subsequent attacks are more likely to present

with vulval soreness as the only noticeable feature.

! Herpes simplex features

• Primary infection:

• general malaise

• fever

• anorexia

• lymphadenopathy

• genital blisters

• urinary retention

• Recurrent (secondary) infection:

• genital blisters

• often occurs at times of stress

or tiredness

The woman probably acquired the infection from her new partner – condoms do not effectively prevent spread as the organism can spread from the perineum. In this case there is also

evidence of herpes cervicitis from spread of virus particles into the vagina.

Further investigation

Vulval viral swab should be sent to confirm the diagnosis. This requires firm rubbing of the

swab onto an ulcer and is very painful, but as the diagnosis has such profound social implications, confirmation of the diagnosis is imperative.

Management

Immediate management:

• The woman should have an indwelling (preferably suprapubic) urinary catheter

inserted immediately and be given analgesia and paracetamol.

• Local anaesthetic gel often relieves the pain and can be used until symptoms

settle.

• Oral aciclovir started within 24 h of an attack reduces the severity and duration

of the episode.

Further management:

• Referral to a health counsellor should be made to discuss the diagnosis and its

implications.

• Some women have many recurrent attacks, whereas others never experience

a further episode. For recurrent attacks aciclovir may be given again if commenced within 24 h of becoming unwell.

KEY POINTS

• Genital herpes simplex infection has a major psychosexual and social impact on

sufferers.

• The first attack is generally severe and associated with primarily systemic features.

• Recurrent episodes may be hardly noticed; transmission may occur prior to the

appearance of blisters and condoms do not prevent spread of disease and so it is

difficult to limit.

• Aciclovir does not cure the disease but is effective at reducing the duration and

severity of an episode.